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List of low priority procedures and other procedures with restrictions or thresholds Policy Number: Version: 5 Ratified by: Risk and Clinical Governance Committee Name of originator/author: Name of responsible committee/individual: Public Health Directorate Public Health Directorate Date issued: January 2010 NHSLA Standard (if applicable): Standards for Better Health (if applicable): Last review date: December 2009 Next review date: March 2010 Equality Impact Assessment Tool Policy and operating procedures for dealing with individual funding requests 1. Does the document/guidance affect one group less or more favourably than another on the basis of: Race Ethnic origins travellers) Nationality Gender Culture Religion or belief Sexual orientation including lesbian, gay and bisexual people Age Disability - learning disabilities, physical disability, sensory impairment and mental health problems (including gypsies Yes/No YES Comments There is potential that some groups are affected differently. A preliminary impact assessment will be undertaken in January 2010 followed by a full equality impact assessment. and 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination, are there any exceptions valid, legal and/or justifiable? 4. Is the impact of the document/guidance likely to be negative? 5. If so, can the impact be avoided? 6. What alternative is there to achieving the document/guidance without the impact? 7. Can we reduce the impact by taking different action? For advice in respect of answering the above questions, please contact Tina Gull Equality and Diversity Lead E-mail: [email protected] Telephone 01932 723543 If you have identified a potential discriminatory impact of this procedural document, please contact as above. Names and Organisation of Individuals who carried out the Assessment please give contact details 2 Date of the Assessment Version Date Author Status Comment 1 November 2009 M. Baker Draft List aligned with W. Sussex and South Central SHA policies 2 November 2009 M. Baker Draft Addition of procedures with evidence of limited effectiveness 3 November 2009 A. Ali Draft 4 November 2009 A. Ali Draft Incorporating procedures with thresholds/restrictions Amendments following comments from Clini-PEC 5 December 2009 A. Ali Final 3 Amendments following comments from CEC Contents Procedure Page 1. Abdominoplasty / Apronectomy 7 2. Acne Scarring 7 3. Acupuncture 7 4. Aromatherapy 7 5. Arthroscopy of the knee 8 6. Asymptomatic Impacted Third Molars 8 7. Bariatric surgery 8 8. Blepharoplasty 8 9. Body Contouring 8 10. Brachioplasty / Upper Arm Lift 8 11. Breast Augmentation 8 12. Breast Reduction 9 13. Brow Lift 9 14. Buttock Lift 9 15. Calf Implants 9 16. Carpal Tunnel Syndrome 9 17. Cataract surgery 9 18. Cerebellar Stimulator Implants 10 19. Chalazia 10 20. Chemical Peels 10 21. Chinese Medicines 10 22. Chiropractic Therapy 11 23. Circumcision 11 24. Clinical Ecology 11 25. Closure of Patent Foramen Ovale for Migraine 11 26. Correction of Inverted Nipple 11 27. Cryotherapy for Localised Prostate Cancer 11 28. Cyberknife for Cholangiocarcinoma 11 29. DaVinci Robotic Radical Prostatectomy for the Treatment of 11 Prostate Cancer 30. Dental Extraction of Non-Impacted Teeth 11 31. Dental extraction of wisdom teeth in children under general 12 anaesthetic 32. Dental Implants 12 33. Dermabrasion of Skin 12 34. Dilation and Curettage 12 35. Dupuytren’s contracture 12 36. Electrolysis 13 37. Endoscopic Thoracic Sympathectomy for Facial Blushing and/or 13 sweating 38. Excimir Laser Surgery for Short Sight 13 39. Excision of Redundant Skin or Fat 13 40. Extra-corporeal Photopheresis for the Treatment of Chronic Graft 14 Versus Host Disease or Cutaneous T Cell Lymphoma 41. Face Lift 14 42. Female genital prolapse 14 4 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. 86. 87. 88. 89. Female Sterilisation Gamma Knife Surgery for Trigeminal Neuralgia Ganglions (Wrist and Foot: Surgical Techniques for the Treatment of) Gender Reassignment Grommets Gynaecomastia Hair Transplant / Hair Graft/ Hair Replacement Herbal Remedies Hip & Knee replacements Hirsutism Treatment Homeopathy Hyperbaric Oxygen Therapy for Wound Healing Hypnotherapy Hysterectomy for Heavy Menstrual Bleeding Inguinal hernia in adults Kyphoplasty Laser Therapy / Laser Treatment for Aesthetic Reasons / Tunable Dye Laser Limb Prosthesis Liposuction Massage Mastopexy Minor Irregularities of Aesthetic Significance Neck Lift Osteopathy Orthodontics Penile Implants Pinnaplasty Plastic Operations on Umbilicus Polysomnography in the Investigation of Children with SleepRelated Disorders Private Treatment Available on the NHS Ptosis of Eyelid Refashioning of Scar Reflexology Removal of Benign Skin Lesions Repair of Lobe of External Ear Residential Pain Management Programmes Retractile Penis Surgery Reversal of Vasectomy / Reversal of Sterilisation Rhinophyma Rhinoplasty / Septorhinoplasty Salvage Cryotherapy for Recurrent Prostate Cancer Skin Grafts for Scars Spinal Cord Stimulation (SCS) for Ischaemic Pain Spinal Fusion for the Treatment of Lower Back Pain Submental Lipectomy Tattoo Removal Temporomandibular Joint Replacement 5 14 15 15 15 16 16 16 17 17 17 17 18 18 18 18 18 18 18 19 19 19 19 19 19 19 19 19 20 20 20 20 20 20 20 20 21 21 21 21 21 21 21 21 22 22 22 22 90. 91. 92. 93. 94. 95. 96. 97. 98. 99. Thigh Lift Tonsillectomies Traumatic Clefts due to Avulsion of Body Piercing Trans-cranial Doppler Ultrasonography with Frequent Transfusion to Prevent Stroke in Children with Sickle Cell Disease Trigger finger Upper Arm Reduction Varicose Veins Vertebroplasty Viral Warts Xanthelasma 6 22 22 22 23 23 23 23 23 23 23 Low Priority Procedures and Other Procedures with Restrictions NHS Surrey has considered evidence of clinical effectiveness and experience, information on current activity, resources, costs and provision across the South East Coast in order to formulate the following recommendations. NHS Surrey has also undertaken a comparative analysis with polices adopted by NHS West Sussex and the South Central (Berkshire PCTs) Priorities Committee and acknowledge with thanks the permission given to utilise their policy statements. There is no blanket ban on these procedures. There is an established mechanism for dealing with individual funding requests/expectations. The application form for clinicians wishing to request funding for individuals that are eligible against the definitions of a “rarity request” or an “exceptionality request” as set out in the NHS Surrey Policy and Operating Procedures for dealing with IFRs is attached to this document as Appendix A. Patients who fulfil the criteria (unless otherwise stated) do not need to be considered by the review panel. However, these procedures will be subject to periodic audits to ensure adherence to the criteria. 1. Abdominoplasty / Apronectomy This procedure is not routinely funded. (In line with South East Coast Policy Recommendation Committee). Bariatric surgeons, GPs and other clinicians supporting patients in losing weight should document discussions with patients: - Regarding the possibility of being left with excess skin after profound weight loss, and informing patients that surgery to remove excess skin is not routinely available on the NHS. Where appropriate, this should be part of the consent process. 2. Acne Scarring Procedures for acne scarring are not routinely funded. 3. Acupuncture This procedure not routinely funded. 4. Aromatherapy This procedure not routinely funded. It is only available occasionally in hospices and hospitals as part of palliative care packages. 7 5. Arthroscopy of the knee Arthroscopy of the knee can be undertaken where a competent clinical examination (or MRI scan if there is diagnostic uncertainty or red flag symptoms/signs/conditions) has demonstrated clear evidence of an internal joint derangement (meniscal tear, ligament rupture or loose body) and where conservative treatment has failed or where it is clear that conservative treatment will not be effective. Knee arthroscopy can therefore be carried out for: Removal of loose body Meniscal surgery (repair or resection) Ligament reconstruction/repair (including lateral relapse) Synovectomy Knee arthroscopy should not be carried out for any of the following indications: Investigation of knee pain Treatment of osteoarthritis including arthroscopic washout and debridement. In line with NICE guidance CG59 this should not be offered as part of treatment for osteoarthritis unless the individual has knee osteoarthritis with a clear history of mechanical locking (not gelling, ‘giving way’) 6. Asymptomatic Impacted Third Molars Surgical extraction of asymptomatic impacted third molars is not routinely funded by NHS Surrey except in the circumstances recommended by NICE as set out below. NICE have issued the following guidance: “Surgical removal of impacted third molars should be limited to patients with evidence of pathology. Such pathology includes unrestorable caries, non-treatable pulpal and/or periapical pathology, cellulites, abcess and osteomyelitis, internal/external resorption of the tooth or adjacent teeth, fracture of tooth, disease of follicle including cyst/tumour, tooth/teeth impeding surgery or reconstructive jaw surgery and when a tooth is involved in or within the field of tumour resection”. 7. Bariatric surgery in adults Funding for bariatric will be considered as a treatment option for adults if the individual has a BMI of 40 kg/m2 or more OR a BMI of 35-40 kg/m2 and other significant disease (for example, type 2 diabetes or high blood pressure) that could be improved if they lost weight All appropriate non-surgical measures must have been tried but have failed to achieve or maintain adequate, clinically beneficial weight loss for at least 6 months. Applications for funding for bariatric surgery should be submitted on the NHS Surrey form (Appendix D) 8. Blepharoplasty This procedure is not routinely funded. NHS Surrey will fund: - The correction of ectropion and entropion 8 NHS Surrey will consider funding this procedure if there is evidence of impairment of visual fields in the relaxed, non compensated state. 9. Body Contouring This procedure is not routinely funded. 10. Brachioplasty / Upper Arm Lift This procedure is not routinely funded. 11. Breast Augmentation This policy is currently being reviewed by the HPSU This procedure is not routinely funded. NHS Surrey will consider funding this procedure if: - History of previous mastectomy or other excisional breast surgery (unilateral or bilateral). - Trauma to the breast during or after development (unilateral or bilateral) - Congenital amastia (total failure of breast development). - Endocrine abnormalities. - If the referral is for developmental asymmetry the patient should have a BMI of between 18 and 25, be aged over 19 over at time of referral (National Service Framework definition of childhood) and have completed puberty. -There must be a natural absence of breast tissue unilaterally and no ability to maintain a normal breast shape using non-surgical methods (e.g. padded bra). Where relevant, treatment of the underlying cause of the problem should have been undertaken. - The degree of asymmetry must meet at least one of the following criteria: - at least 30% difference in volume between breasts; - ≥ 4cm difference in sternal notch to nipple measurement between Breasts; - ≥ 30% difference in nipple to inframammary fold measurement between breasts; - ≥ 50% difference in nipple areolar diameter between breasts. The wearing of a professionally fitted brassiere has not relieved the symptoms If revisional surgery is being carried out for implant failure, the decision to replace the implant(s) rather than simply remove them will be based upon the clinical need for replacement and whether the patient meets the criteria for augmentation at the time of revision. 12. Breast Reduction This policy is currently being reviewed by the HPSU This procedure is not routinely funded. 9 NHS Surrey will consider funding this procedure if: - The patient has a body mass index (BMI) of <28kg/m 2 AND - The patient is suffering from neck ache, backache, shoulder pain, breast pain, shoulder grooving, headache, pain +/- numbness in the hand and/or Intertrigo. If referral is for pain there should be documented evidence of the patient consulting with the GP for this problem, the duration of the pain and evidence that other approaches e.g. analgesia, physiotherapy have been tried. The wearing of a professionally fitted brassiere has not relieved the symptoms 13. Brow Lift This procedure is not routinely funded. 14. Buttock Lift This procedure is not routinely funded. 15. Calf Implants This procedure is not routinely funded. 16. Carpal tunnel syndrome (Surgical Techniques for the Treatment of) NHS Surrey will only fund this intervention if: Acute, severe symptoms persist after conservative therapy with either local corticosteroid injection and/or nocturnal splinting OR Mild to moderate symptoms persist for at least 4 months after conservative therapy with either local corticosteroid injection (if appropriate) and/or nocturnal splinting (used for at least 8 weeks) OR There is neurological deficit e.g. sensory blunting, muscle wasting or weakness of thenar abduction OR Severe symptoms significantly interfere with daily activities 17. Cataract surgery Adults with a visual acuity of 6/9 or better in either eye are considered a low priority for cataract surgery. Referrals from community services should only be made after an assessment by an optometrist unless there are exceptional reasons why this is not possible. Optometrists should take into account the referral thresholds and the impact of the cataract(s) on the patient’s life. Referral of patients to ophthalmologists should be based on the following indications: 1. Best corrected visual acuity (assessed by high contrast testing) Documented to be at least 6/10 or worse in the affected eye for drivers OR Documented to be at least 6/12 or worse in the affected eye for nondrivers OR Documented to be at least 6/18 or worse in the affected eye irrespective of the acuity of the other eye OR 10 The patient wishes to/is required to drive and does not meet Driving & Licensing Authority (DVLA) eyesight requirements 2. AND impairment of lifestyle such as; The patient is at significant risk of falls OR the patient’s vision is substantially affecting their ability to work OR the patient’s vision is substantially affecting their ability to undertake leisure activities such as reading, recognising faces or watching television 3. AND willingness to have cataract surgery; The referring optometrist or GP has discussed the risks and benefits and ensured the patient understands and is willing to undergo surgery prior to referral Patients should only undergo surgery of the second eye when that eye meets the thresholds outlined above. Funding will be considered for patients with severe anisometropia who wear glasses. Any suspicion of cataracts in children should be referred urgently 18. Cerebellar Stimulator Implants This procedure is not routinely funded. (In line with South Central (Berkshire PCTs) Priorities Committee Policy) 19. Chalazia This procedure is not routinely funded. Chalazia (meibomian cysts) are benign, granulomatous lesions that will normally resolve within 6 months. Treatment consists of regular (four times daily) application of heatpacks. NHS Surrey will fund excision of chalazia when all of the following criteria are met: - The chalazia has been present for more than 6 months - Where it is situated on the upper eyelid - Where it is causing blurring of vision In common with all types of lesions, NHS Surrey will fund removal where malignancy is suspected. 20. Chemical Peels This procedure is not routinely funded. 21. Chinese Medicines These therapies are not routinely funded. 22. Chiropractic Therapy This procedure is not routinely funded. 11 23. Circumcision This procedure is not routinely funded. NHS Surrey will fund circumcision when the procedure is for: - Patients with severe phimosis - Severe recurrent balanitis - Where cancer is suspected 24. Clinical Ecology These procedures are not routinely funded. 25. Closure of Patent Foramen Ovale for Migraine This procedure is not routinely funded. (In line with South Central (Berkshire PCTs) Priorities Committee Policy). 26. Correction of Inverted Nipple This procedure is not routinely funded. 27. Cryotherapy for Localised Prostate Cancer This procedure is not routinely funded. (In line with South Central (Berkshire PCTs) Priorities Committee Policy) 28. Cyberknife for Cholangiocarcinoma This procedure is not routinely funded. 29. DaVinci Robotic Radical Prostatectomy for the Treatment of Prostate Cancer This procedure is not routinely funded. (In line with South Central (Berkshire PCTs) Priorities Committee Policy) 30. Dental Extraction of Non-Impacted Teeth Extraction of non-impacted teeth will not be routinely funded in secondary care. However, NHS Surrey will consider funding for patients with the risk factors listed below through the agreed mechanism. NHS Surrey has a process for triaging dental referrals into secondary care. - Those at high risk of endocarditis who require intravenous antibiotics - Those undergoing a course of intravenous bisphosphonates - Those who have suffered a myocardial infarct or undergone coronary revascularisation within 6 months of referral - Those who are known to have brittle asthma - Those who have a clear need for a general anaesthetic 31. Dental extraction of wisdom teeth in children under general anaesthetic This procedure is not routinely funded. 12 32. Dental Implants Dental implants are not routinely funded except under the following conditions: - Patients undergoing oral/facial rehabilitation following major loss of issue as a result of ablative surgery. - Patients undergoing oral/facial rehabilitation following major loss of issue as a result of trauma. - Correction of congenital maxillo-facial anomalies, e.g. cleft palates and other syndromes, where the abnormality, or the process of correcting it, make it impossible for other prostheses to be used. - Treatment of hypodontia when other treatment options have failed or be deemed inappropriate. Treatment would not normally include a single missing tooth in an arch. Minimum criteria should be 4 units in an arch, but where space closure has been achieved a result of orthodontic treatment, any assessment will be based on the number of missing units post-treatment. - Rehabilitation of the severely dentally disabled patient, especially those in whom health is compromised, and for whom, conventional dental treatment has failed or is deemed to be inappropriate. These criteria should be regarded as guidelines. There may be a case where, although it does not fit into these criteria, the referring practitioner considers the insertion of dental implants justified. All cases should be referred to the Acute Contracting team for consideration. 33. Dermabrasion of Skin This procedure is not routinely funded. 34. Dilation and Curettage The Department of Health uses a basket of five procedures as an indicator or excess surgical activity. Dilation and curettage is one of these procedures. NHS Surrey will fund dilation and curettage for diagnostic purposes for suspected malignancy and for evacuation of retained products of conception. The procedure will not be routinely funded for other reasons. 35. Dupuytren’s contracture This procedure is not routinely funded. NHS Surrey may consider funding this procedure if there is a metacarpophalangeal joint contracture of 30o or more OR any degree of proximal interphalangeal joint contracture OR patients under 45 years of age with disease affecting 2 or more digits and loss of extension exceeding 10 o or more 36. Electrolysis This procedure is not routinely funded. 37. Endoscopic Thoracic Sympathectomy for Facial Blushing and/or sweating 13 This procedure is not routinely funded. (In line with South Central (Berkshire PCTs) Priorities Committee Policy). 38. Excimir Laser Surgery for Short Sight This procedure is not routinely funded. 39. Excision of Redundant Skin or Fat This procedure is not routinely funded. 40. Extra-corporeal Photopheresis for the Treatment of Chronic Graft Versus Host Disease or Cutaneous T Cell Lymphoma This procedure is not routinely funded. (In line with South Central (Berkshire PCTs) Priorities Committee Policy) 41. Face Lift This procedure is not routinely funded. 42. Female genital prolapse (Surgical management of) This procedure is not routinely funded for asymptomatic or mild pelvic organ prolapse. Referral for specialist assessment is indicated for: Prolapse combined with urethral sphincter incompetence or faecal incontinence Moderate to severe symptoms Failure of pessary 43. Female Sterilisation Sterilisation will not be available on non medical grounds unless the woman has had at least 12 months' trial using Mirena or Implanon and found it unsuitable. NHS Surrey will fund this procedure if: - Where sterilisation is to take place at the time of another procedure such as caesarean section. - Where there is a clinical contraindication to the use of a Mirena/Implanon. - Where there are severe side effects with the use of Mirena/Implanon. - Where there is an absolute clinical contraindication to pregnancy. These are:- young women (under 45 years of age) undergoing endometrial ablation for heavy periods - women with severe diabetes - women with severe heart disease Women should be informed that vasectomy carries a lower failure rate in terms of post-procedure pregnancies and that there is less risk related to the procedure. 44. Gamma Knife Surgery for Trigeminal Neuralgia 14 This procedure is not routinely funded. (In line with South Central (Berkshire PCTs) Priorities Committee Policy). 45. Ganglia (Wrist and Foot: Surgical Techniques for the Treatment of) This procedure is not routinely funded unless there is evidence of nerve or blood vessel compression. 46. Gender Reassignment This policy is currently being reviewed. Gender re-assignment is a highly specialised area of clinical practice and should only be considered, assessed for and carried out as part of a recognised NHS programme of care. Each case will be considered on its individual merits. NHS Surrey does not routinely fund cosmetic surgery and other procedures such as breast augmentation, wigs, hair removal, rhinoplasty, jaw reduction, liposuction, reduction thyroid chondroplasty, blepharoplasty, face lift etc. Additional speech and language therapy outside that provided by West London Mental Health NHS Trust will not be funded. Clinicians with patients wishing to be considered for these treatments can make an application to the Exceptions Panel. Storage of gametes to preserve reproductive potential will be considered on an individual basis in line with the NHS Surrey’s fertility treatment policy. NHS Surrey will consider funding gender re-assignment if: - Patients aged 18 years or over and competent to consent to receive treatment consistent with safe clinical practice. - Patient has been diagnosed by a specialist psychiatrist as having gender identity disorder. Patient has been assessed by a consultant psychiatrist to confirm the absence of significant mental illness. - Have lived as a member of the gender they wish to be assigned to, continuously and successfully, full time, for at least the preceding 2 years (Real Life Experience). - Regular, responsible participation in psychological support/psychotherapy during the real life experience as agreed with a specialist mental health professional. - Patients should have continued with an established supervised course of hormone reassignment therapy. (usually 12 months for those without a medical contraindication). - Patient has diagnosed gender identity disorder and has been assessed, counselled and signed off as fit for surgery by two psychiatrists specialising in gender identity disorder. - Patient has been referred by a specialist Gender Identity Clinic for assessment for surgery to a specialist gender reassignment surgery centre. 15 - Patient should have a demonstrable knowledge of the required lengths of hospitalisations, likely complications and post surgical rehabilitation requirements of the various surgical interventions. - Patient intends to live in the acquired gender until death. 47. Grommets Grommets for children should be undertaken in accordance with NICE Clinical Guidance 60 (Feb 2008) Surgical Management of Otitis Media with Effusion in Children. This procedure is not routinely funded for adults (≥ 18 years old) except under the following conditions: - A middle ear effusion causing measured conductive hearing loss, persisting for at least 6 months and resistant to medical treatments. The patient must be experiencing disability due to deafness. The possible option of a hearing aid may be discussed, at the discretion of the clinician. - Persistent Eustachian tube dysfunction resulting in pain (e.g. flying) - As one possible treatment for Meniere’s disease. - Severe retraction of the tympanic membrane if the clinician feels this may be reversible and reversing it may help avoid erosion of the ossicular chain or the development of cholesteatoma. - Grommet insertion as part of a procedure for the diagnosis or management of head and neck cancer and/or its complications 48. Gynaecomastia This policy is currently being reviewed by the HPSU Procedures to treat gynaecomastia in men are not routinely funded. NHS Surrey may consider funding if: - BMI <25 - AND - Age 19 years or over at time of referral (National Service Framework definition of childhood) and has completed puberty - Male breast cancer, underlying endocrine disorder and drug related causes excluded. - Surgical intervention recommended by consultant breast/plastic surgeon - Group 2B or 3 gynaecomastia - Reduction will be significant ≥100g per side as assessed by the consultant breast/plastic surgeon 49. Hair Transplant / Hair Graft / Hair replacement Hair replacement/ hair transplant/grafting is not routinely funded. Hair pieces and wigs for patients experiencing total hair loss as a result of alopecia totalis, previous surgery or trauma are available from local NHS Trusts. 16 50. Herbal Remedies This is not routinely funded. 51. Hip & Knee replacements Patients should be referred for consideration of total joint replacement when all conservative means have failed to alleviate the patient’s pain and disability, which should be significantly interfering with their activities of daily living and their ability to sleep. Referral for specialist assessment should only be considered if the patient has: Moderate to severe pain not adequately relieved by an extended course of non-surgical treatment (such as adequate doses of analgesia, weight control and physical therapies) AND clinically significant functional limitation resulting in diminished quality of life AND radiographic evidence of joint damage The following conservative management should have been attempted (where appropriate): 1. Advice to reduce BMI to less than 30 and the patient having complied with this. All reasonable attempts should be made to reduce weight to a BMI below 30 prior to referral. 2. Simple analgesia. 3. Anti-inflammatory analgesia (where appropriate) 4. Advice on exercise and if appropriate physiotherapy. 5. Advice on walking aids, home adaptations, curtailment of inappropriate activities and general counselling on the potential risks and benefits of joint replacement surgery 6. Underlying medical conditions should have been investigated and the patients condition optimised prior to referral Ideally patients should: 1. Have had efforts to reduce/eradicate open ulcers, recurrent infections or MRSA colonisation These criteria are subject to review pending the outcome of work on hip and knee replacements by the local Orthopaedic Network 52. Hirsutism Treatment Hair removal procedures for hirsutism are not routinely funded. 53. Homoeopathy This is not routinely funded. 54. Hyperbaric Oxygen Therapy for Wound Healing 17 This procedure is not routinely funded. 55. Hypnotherapy This procedure is not routinely funded. 56. Hysterectomy for Heavy Menstrual Bleeding This procedure will only be funded in line with NICE guidance (CG44 Jan 2007). Pharmaceutical treatment should be considered as first line intervention for women with no structural or histological abnomrlaity suspected or fibroids less than 3cm in diameter. In women with heavy menstrual bleeding alone, with a uterus no bigger than a 10 week pregnancy, endometrial ablation should be considered preferable to hysterectomy. Hysterectomy should only be considered when: - other treatment options have failed, are contraindicated or are declined by the woman - there is a wish for amenorrhoea - the woman (who has been fully informed) requests it - the woman no longer wishes to retain her uterus and fertility 57. Inguinal hernia in adults (Elective surgical repair of) This procedure is not routinely funded for asymptomatic or mildly symptomatic inguinal hernias in adults. Patients should be referred for surgical assessment if they meet the following criteria: 1. A history of incarceration of, or real difficulty reducing, the hernia 2. An inguino-scrotal hernia 3. Increase in size month to month 4. Pain or discomfort significantly interfering with activities of daily living 5. Work related issues e.g. of work/missed work/unable to work/on light duties due to hernia Patients with femoral hernias should be referred for consultation. 58. Kyphoplasty This procedure is not routinely funded. (In line with South Central (Berkshire PCTs) Priorities Committee Policy) 59. Laser Therapy / Laser Treatment for Aesthetic Reasons / Tunable Dye Laser NHS Surrey will not routinely fund this procedure for cosmetic problems. Laser treatments is currently being reviewed by the HPSU 60. Limb prosthesis These are available on the NHS and will therefore not be funded privately. 18 61. Liposuction NHS Surrey will not routinely fund cosmetic liposuction. However, liposuction may be used as part of other surgery, e.g. thinning of transplanted flap. 62. Massage This procedure is not routinely funded. The procedure is sometimes available in hospices as part of a palliative care package. 63. Mastopexy This policy is currently being reviewed by the HPSU This procedure is not routinely funded. NHS Surrey may consider funding this procedure as part of the treatment for breast asymmetry and reduction but will not be funded for purely cosmetic/ aesthetic indications such as post-lactational ptosis, age related breast ptosis or after weight loss. The patient will also need to have a body mass index (BMI) of <28kg/m2 if indicated for treatment of breast asymmetry and reduction. The wearing of a professionally fitted brassiere has not relieved the symptoms 64. Minor Irregularities of Aesthetic Significance This procedure is not routinely funded. 65. Neck Lift This procedure is not routinely funded. 66. Osteopathy This procedure is not routinely funded. 67. Orthodontics (Grade 3.5 and below on the Index of Orthodontic Treatment Need) These procedures are not routinely funded. NHS Surrey has a process for triaging dental referrals into secondary care. 68. Penile Implants This procedure is not routinely funded. 69. Pinnaplasty This procedure is not routinely funded. 19 70. Plastic Operations on Umbilicus This procedure is not routinely funded. 71. Polysomnography in the Investigation of Children with Sleep-related Disorders This procedure is not routinely funded. (In line with South Central (Berkshire PCTs) Priorities Committee Policy) This procedure will be subject to review. 72. Private Treatment Available on the NHS When clinicians retire from the NHS they may continue to practice privately. There are often patients who wish to continue seeing them, rather than see a new NHS clinician. NHS Surrey will not routinely fund private consultations in these circumstances. 73. Ptosis of Eyelid This procedure is not routinely funded. NHS Surrey will consider funding this procedure if there is evidence of impairment of visual fields 74. Refashioning of Scar This procedure is not routinely funded. 75. Reflexology This procedure is not routinely funded. 76. Removal of Benign Skin Lesions This policy is currently being reviewed by the HPSU: due January 2010. This procedure is not routinely funded. Clinically benign skin lesions should not be removed on purely cosmetic grounds. Patients with moderate to large lesions that cause actual facial disfigurement may benefit from surgical excision. The risks of scarring must be balanced against the appearance of the lesion. The decision to remove benign skin lesions from conspicuous sites is a balance between the appearances of the original lesion against the likely appearance of the surgical scar. It is therefore essential that the decision is made by a practitioner fully familiar with the factors affecting the outcome of surgery in these sites and that the excision is carried out by a trained practitioner using fine instruments and sutures in an appropriate surgical setting. PLEASE NOTE: NHS Surrey funds biopsy or excision of a lesion whenever there is concern that the lesion might have malignant potential. Such cases do not need approval by NHS Surrey. The degree of suspicion of malignancy is a matter of clinical judgement by the referring clinician. 20 77. Repair of Lobe of External Ear This procedure is not routinely funded. 78. Residential Pain Management Programmes These are not routinely funded. 79. Retractile Penis Surgery This procedure is not routinely funded. 80. Reversal of Vasectomy / Reversal of Sterilisation NHS Surrey will not routinely fund reversal of vasectomy and female sterilisation reversals. Patients who have a sterilisation procedure should be made aware that subsequent reversal of sterilisation will not normally be available on the NHS. 81. Rhinophyma Treatment for this condition is not routinely funded. 82. Rhinoplasty / Septorhinoplasty These procedures are not routinely funded. NHS Surrey will only fund these procedures as a package of reconstructive surgery to restore function as part of a total package of surgery following major trauma [at the time that the surgery takes place] or to repair cleft palate. 83. Salvage Cryotherapy for Recurrent Prostate Cancer This procedure is not routinely funded. (In line with South Central (Berkshire PCTs) Priorities Committee Policy). 84. Skin Grafts for Scars This procedure is not routinely funded NHS Surrey will fund this treatment for burns and as part of reconstruction following major trauma. 85. Spinal Cord Stimulation (SCS) for Ischaemic Pain This procedure is not routinely funded. (In line with South Central (Berkshire PCTs) Priorities Committee Policy). As an exception to this general policy, NHS Surrey consider that treatment may be considered an option in refractory angina and cardiac syndrome X if the patient meets all of the following criteria: - has coronary heart disease or cardiac syndrome X which cannot be treated satisfactorily by medication; 21 - is not suitable for a revascularisation procedure (in the case of coronary heart disease); - has been assessed and treated by a pain clinic but still suffers unacceptable symptoms; - has been referred to the National Refractory Angina Centre at Broadgreen Hospital; - is recommended by the National Refractory Angina Centre to have spinal cord stimulation; - shows a reduction in pain after trial spinal cord stimulation of at least 50%. 86. Spinal Fusion for the Treatment of Lower Back Pain This procedure will only be funded in line with NICE guidance (CG88). Consider referral for an opinion on spinal fusion for people who: - have completed an optimal package of care, including a combined physical and psychological treatment package - still have severe non-specific lower back pain for which they would consider surgery 87. Submental Lipectomy This procedure is not routinely funded. 88. Tattoo Removal This procedure is not routinely funded. 89. Temporomandibular Joint Replacement This procedure is not routinely funded. (In line with South Central (Berkshire PCTs) Priorities Committee Policy). 90. Thigh Lift This procedure is not routinely funded. 91. Tonsillectomies +/- adenoidectomies This procedure is not routinely funded except in children and adults who fulfil the criteria outlined below. Eligibility Criteria - Cases of suspected malignancy - Sore throats must be due to tonsillitis and must be “disabling and prevent normal functioning”, the symptoms must have been present for at least a year and there must have been five or more episodes a year, two or more weeks absence from work/school/college/duties as a carer. - Tonsillitis or quinsy requiring two or more hospital admissions - Tonsillar enlargement causing upper airways obstruction. 92. Traumatic Clefts due to Avulsion of Body Piercing This procedure is not routinely funded. 22 93. Trans-cranial Doppler Ultrasonography with Frequent Transfusion to Prevent Stroke in Children with Sickle Cell Disease This procedure is not routinely funded. (In line with South Central (Berkshire PCTs) Priorities Committee Policy). 94. Trigger finger (surgical techniques for the treatment of) This procedure is not routinely funded. NHS Surrey may consider funding this procedure if a patient has failed to respond to conservative treatment (including at least 2 corticosteroid injections) OR has a fixed flexion deformity that cannot be corrected. 95. Upper Arm Reduction This procedure is not routinely funded. 96. Varicose Veins This policy is currently being reviewed by the HPSU: Due January 2010 NHS Surrey does not routinely fund the treatment of Class I and II varicose veins. See appendix B 97. Vertebroplasty This procedure is not routinely funded. 98. Viral Warts Viral warts are usually of aesthetic significance only and surgical removal is not routinely funded by NHS Surrey. However, NHS Surrey will fund removal of viral warts in patients who are immunocompromised. There are no restrictions on treatment of genital warts. 99. Xanthelasma This procedure is not routinely funded. Cochlear implants This intervention is funded under the criteria stated in the relevant NICE guidance. The application form for funding is attached to this document (Appendices E & F) Bone anchored hearing aids This intervention is funded under the criteria stated in the relevant NICE guidance. The application form for funding is attached to this document (Appendix G) Adding procedures to the low priorities list Before interventions are added to the list of low priority procedures they will pass through a defined process within NHS Surrey. This process is outlined in Appendix C. 23 APPENDIX A INDIVIDUAL FUNDING REQUEST FORM Please read the guidance notes on the back page before completing this form PART 1: DETAILS OF PATIENT AND CLINICIAN SUBMITTING REQUEST Name: Designation: NHS Trust or GP Details of clinician submitting the request practice: Correspondence address: Tel: Email: Family name: Given names: Address (including Patient details Postcode): NHS Number: 24 Date of Birth: M or F Registered GP name: Registered GP practice: Hospital id no: (if applicable) Does the patient or his/her representative wish to receive letters regarding this request? yes no If YES are the letters to be sent to the patient at the address above? yes no Instructions for communicating with the patient If letters are to be sent to anyone other than the patient, please provide the following information, and obtain the patient’s written agreement: Name Relationship to patient Address (including Postcode) 25 PART 2: INFORMED CONSENT AND PROVIDER TRUST APPROVAL I affirm that I have discussed this Individual Funding Request with my patient. This request is being made with his/her consent. The instructions for communicating with the patient at Clinician’s affirmation of patient’s consent Q3 are his/her expressed wishes. Signature Name: Designation: NHS Trust GP/dental practice Private sector Other Name of NHS Trust/GP/dental practice: Which organisation will be providing the treatment requested? If provider is outside the NHS, please give details of name and location Name of representative: Approved by representative of NHS Trust/GP practice where the treatment will be provided Designation: Signature or email confirmation: 26 If this funding request is approved, the NHS provider will be notified. Please give details for the person who should be notified: Name: Designation: Contact details: PCT use only: Date received: Identifier: Identifier assignment checked by: Please note, pages 1 and 2 containing confidential details of patient’s name, etc. will be removed before the remainder of the form is copied and seen by IFR panel members 27 PART 3: STATEMENT TO CONFIRM APPROPRIATENESS FOR CONSIDERATION BY IFR PANEL If it is foreseeable that there are one or more other patients within the PCT population who are or are likely to be in the same or similar clinical circumstances as the requesting patient in the same financial year, and who could reasonably be expected to benefit to the same or a similar degree from the requested treatment then the request should properly be considered as a request for a service development and inappropriate for consideration by an IFR Panel except in the circumstances where all the similar patients are expected to be from the same family group, a situation which may arise in the context of a rare genetic disease. I confirm that it is not expected that there will be NO YES more than one patient from within the PCT population who is or is likely to be in the same or similar clinical circumstances as the requesting patient in the same financial year and who could reasonably be expected to benefit to the same or a similar degree from the requested treatment unless similar patients are expected to be from the same family group. 28 PART 4: DIAGNOSIS AND PATIENT’S CURRENT CONDITION Diagnosis (for which the intervention is requested) Has a second consultant opinion been obtained? If YES, please give details What is disease status? (e.g. at presentation,1st,2nd or 3rd relapse) Current status of the patient: (a) Intervention for cancer: What is the WHO performance status? How advanced is the cancer? (stage) Describe any metastases: What is the patient’s clinical severity? (Where possible use (b) Intervention for standard scoring non-cancer systems e.g. WHO, PASI, DAS scores, walk test, cardiac index etc.) 29 Please summarise the current status of the patient in terms of quality of life, symptoms etc. Summary of previous interventions for this condition Nature of Reason for stopping*/ intervention response achieved Dates Reasons for stopping may include: course completed no or poor response disease progression adverse effects / poorly tolerated 30 PART 5: INTERVENTION FOR WHICH FUNDING IS REQUESTED Drug Surgical procedure Medical device Therapy Other (give details) Nature of the intervention If combination, tick all that apply and complete 6A and 6B Name of intervention Where will intervention be provided? Indicate whether in-patient, out-patient, daycase Is the requested intervention a continuation of existing treatment funded via another route? NO funding YES - give details of existing arrangement and why ceased NO YES - give details Is the intervention experimental, part of a trial or research? PART 6A: INTERVENTIONS INVOLVING DRUGS Full name of drug and manufacturer Planned dose and frequency Planned duration of intervention Route of administration Optimal start date If the intervention forms part of a regimen, please document in full Drug licensed for requested indication in the UK? Drug listed as a PBR exclusion? Estimated costs (e.g. Drug X as part of regimen Y (consisting of drug V, drug W, drug X and drug Z). YES NO YES NO Anticipated cost (inc VAT) 31 Please consult Pharmacy team for current contract prices as these may differ from those stated in BNF or other sources. Are there any offset costs? YES NO Describe the type and value of offset costs Funding difference being applied for PART 6B INTERVENTIONS INVOLVING SURGICAL PROCEDURES, THERAPIES, DEVICES Describe the intervention as it applies to this patient Is this intervention listed by the PCT as a Procedure Not Normally Funded YES NO Specify any devices, prostheses, etc. and the manufacturer Anticipated cost (inc VAT) Are there any offset costs? Estimated costs Please consult the relevant business manager for assistance Describe the type and value of offset costs 32 YES NO Funding difference being applied for PART 7: PROJECTED OUTCOMES If so, please describe the standard intervention Is there a standard intervention for this patient at this stage of their condition? What would be the expected outcome from the standard intervention? Why is the standard intervention inappropriate for this patient? What would you consider to be a successful outcome for the requested intervention in this patient? This may include likely OS, TTP or improvement in QOL. Please relate to measures describing patient’s condition in Part 3. Please outline any anticipated or likely adverse effects of the requested treatment for this patient, including the toxicity of any drug? PART 7 CONT. How would you monitor the effectiveness of the requested intervention? Pease refer to the measures used to describe the patient’s condition in Part 3 33 What is the minimum timeframe/course of treatment after which a clinical response can be assessed? What are the likely consequences for the patient if this request is not approved? PART 8: STATEMENT OF EXCEPTIONALITY OR RARITY: Exceptional clinical circumstances OR On which basis are you making this request? Rarity of condition or presentation For exception to existing policy, please describe as clearly as possible why the patient’s clinical circumstances are exceptional. You must give specific information to indicate how this patient is significantly different to the population considered in the existing policy For rare condition or presentation, please describe as clearly as possible why this patient’s condition or clinical presentation is so unusual that there is no relevant commissioning arrangement. 34 PART 9: EVIDENCE OF CLINICAL EFFECTIVENESS Give details of published data supporting the use of the requested intervention for this condition. Please provide references or attach articles. PART 10: URGENCY Only a small minority of requests can be decided using the PCT’s fast-track procedure. If there are compelling clinical reasons why this patient’s request should be fasttracked, please state them here. Thank you for completing this form; please send it to: For drug IFR requests please send as an electronic attachment to [email protected] (from 1st April 2010 please send via web-based database https:\\www.healthlinx.co.uk\highcost-trust) For intervention IFR requests please send as an electronic attachment to [email protected] or post to: Acute Contracting (TNRF) Team, NHS Surrey Pascal Place, Randalls Research Park Randalls Way Leatherhead Surrey. KT22 7TW Or Safe Haven Fax: 01372 202690 35 GUIDANCE NOTES FOR CLINICIANS COMPLETING THIS IFR FORM IFR Policy and further information SEC PCTs have adopted a SEC-wide approach to the management of IFRs. An information note for clinicians is available from < website >. Before submitting an IFR, please check you are using the correct process. IFRs can be submitted by an NHS consultant, a GP or dental practitioner, or an equivalent autonomous practitioner where he/she will be responsible for administering the treatment. The requesting clinician is responsible for providing all supporting information and evidence. If treatment is to be provided at an NHS Trust, the IFR must be approved, and this form signed, by the appropriate representative of that NHS organisation. This will usually be the chief pharmacist or a business manager (or their nominated deputy). This approval ensures that capacity issues have been considered. Uncertain? We WANT to help you! Every PCT’s IFR team would much rather answer your questions now than send the form back to you because it is not properly completed. If you would like help to complete this form, please don’t hesitate to contact the appropriate PCT IFR team (see instructions for sending your form below). Why all these questions? Please be assured there is good reason for all the questions on this form. Not every question need be answered for every case; but please signify ‘not applicable’ rather than leaving a blank. Part 1: Details of patient and clinician submitting the request We need to contact you – so full details every time please. We must be able to identify the patient. Please ask your patient to choose whether s/he wishes to receive correspondence about the progress of his/her IFR: if YES please indicate where letters should be directed. Part 2: Informed consent and provider approval Your signature at this point validates the whole request. Details of the provider (and approval, where appropriate) are essential. An unsigned form cannot be accepted. Part 3: Statement to confirm appropriateness for consideration by IFR panel Affirmation of the statement confirms that, to the best of your knowledge, the request is an appropriate IFR. Where you are unable to confirm the statement, your request for funding will need to be considered via another mechanism. Part 4: Diagnosis and the patient’s condition The fullest possible information will help the panel make a decision. Q8 will not be relevant to every case. At Q9 complete either (a) or (b). Q11 may not be relevant to every case. Part 5: Intervention for which funding is requested Please name the intervention clearly, and describe the detail if necessary. If the answer to either Q15 or Q16 is YES, please provide the details separately if the space on the form is insufficient. Part 6A: Interventions involving drugs / Part 6B: Interventions involving surgical procedures, etc. 36 In most cases it will only be necessary to complete either A or B. It is likely that this information will be required before the NHS provider can approve the form. Information on likely costs helps the PCT to be aware of potential cost pressures. Part 7: Projected outcomes Again, the fullest possible information will help the panel come to their decision. Part 8: Statement of exceptionality or rarity At Q38 you must choose either exception or rarity - otherwise the form will be returned. At Q39 please state as clearly as possible, and with reference to the existing policy, why your patient should be treated as an exception; OR at Q40 provide clear information about the rarity of your patient’s condition or presentation. Part 9: Evidence of clinical effectiveness Comprehensive information and accurate references will help to get your IFR through the process quickly. Part 10: Urgency The PCT aims to deal with all IFRs as quickly as possible. Each IFR can only be decided when sufficient information is available to inform the decision. Urgency will be evaluated on the basis of clinical need. For help in filling this form out in relation to drug IFRs please email your query to the Pharmaceutical Commissioning Team at [email protected] who will be able to help you. For help in filling this form out in relation to other intervention IFRs please email your query to the TNRF Team at [email protected] 37 APPENDIX B: - The Varicose Vein Prioritisation Protocol With thanks to Southern Derbyshire Acute Hospitals NHS Trust 38 39 Appendix C Adding Additional Procedures to the Low Priorities List Process To submit additional procedures to the list of low priority procedures (LPP) the following process will be followed. Additions will be undertaken on a quarterly basis to coincide with contract reviews and allow time for clinical engagement. PH/SADD/MADD request a procedure be considered for adding to the LPP list Evidence review undertaken by Public Health looking at clinical and cost effectiveness Not Recommend NICE and clinical quality group Recommend To be approved by appropriate programme Board E.g. Planned care Risk and Clinical Governance Group For organisational ratification 40 Added to LPP list Appendix D Surrey PCT Application for Consideration for Funding for Bariatric Surgery Please complete this form carefully and as fully as possible The application must be supported by the sufficient evidence of all previous non surgical treatments for weight loss. Requests that do not give sufficient evidence will be returned which will result in delay the processing the application. NHS Surrey will consider funding surgery as a treatment option for adults with obesity if all of the following criteria are fulfilled. They have a BMI of 40 kg/m2 or more A BMI of 35-40 kg/m2 and other significant disease (for example, type 2 diabetes or high blood pressure) that could be improved if they lost weight. Or And All appropriate non-surgical measures have been tried but have failed to achieve or maintain adequate, clinically beneficial weight loss for at least 6 months. The person has been receiving or will receive intensive management in a specialist obesity service, is generally fit for anesthesia and surgery, and commits to the need for long-term follow-up. In line with NICE guidance Surrey PCT will consider applications for funding for bariatric surgery providing the individual meets the criteria. Each request is considered individually. It is crucial that the supporting evidence requested on this form is completed in as much details as possible. Name of person requesting funding GP Name and Surgery Patients NHS Number Patient Date of Birth Patient Postcode BMI (Please include Height/Weight) BMI Height Weight Consultant Name Hospital Please complete the following sections in as much detail as possible Clinical Criteria Required for Consideration for Surgery Please Tick and add details where requested 41 1. Patient >18 Years Yes No 2. BMI > 40 kg/m2 Yes No 3. BMI 35-40 kg/m2 Yes No Please give details of other significant disease 4. Patient has received treatment in a recognised specialist obesity clinic, Yes No Please give details: (Example: West Surrey Weight Management Scheme) Dates: From: To: Weight Before: Weight After: 5. Details of appropriate non-surgical measures which have been tried. Dietary Advice: (copy of report required with this application) Weight After: Life Style Modification: Start Date: End Date: Weight Before: Sufficient evidence of previous weight loss interventions is required for approval for funding. Details of these interventions be found in the NICE Obesity Guidance End Date: Weight Before: NICE Guidance requires the following prior to recommending bariatric surgery “All appropriate non-surgical measures have been tried but have failed to achieve or maintain adequate, clinically beneficial weight loss for at least 6 months.” Start Date: Weight After: Available at www.nice.org.uk/nicemedia/pdf/CG43quickrefguide2.pdf 42 Low and very low calorie diets Start Date: End Date: Weight Before: Weight After: Exercise Advice and Programmes: Start Date: End Date: Weight Before: Weight After: Drug Therapy: Start Date: End Date: Weight Before: Weight After: 6. Does the patient have any specific medical or psychological reasons why the surgery may not be performed? 7. Is the patient (in your opinion) fit enough to have a general anesthetic? Yes 8. Have you discussed the need for long term follow up with the patient? Yes 9. Has the patient been receiving or will receive intensive management in a specialist obesity service Yes No Please give details Yes No Please give details No Please give details No Please give details The patient will require full anesthetic assessment in the event of surgery being funded 43 10. If funding can not be approved what is the possible alternative outcome? 11. Please give any further information you feel will be important in this case, for example exceptional circumstances. I confirm that the information on this application form concerning the named patient is correct to the best of my knowledge. Signed Position Date Contact Details Please return completed application form to: Acute Contracting Team Surrey PCT Pascal Place Randalls Research Park Randalls Way Leatherhead Surrey KT22 7TW Fax: 01372 202690 44 Appendix E CHECK LIST FOR APPLICATION FOR CONSIDERING FUNDING FOR COCHLEAR IMPLANTS IN UNDER 18’S Please complete the check list below to indicate which of the following criteria the patient meets Does the child already have a cochlear implant? Does the child have severe to profound deafness (defined as hearing only sounds that are louder than 90dB HL at 2 and 4kHz without acoustic hearing aids in the better hearing ear) ? Please provide relevant test results – audiograms etc. Has the child had a minimum of 3 months use of optimal digital hearing aids, prior to referral for assessment (unless contraindicated or inappropriate)? Does the patient receive adequate benefit from acoustic hearing aids? Has the child had a multidisciplinary assessment? Has there been a failure to develop, progress or maintain speech, language and listening skills appropriate to the child’s age, developmental stage and cognitive ability? Has testing taken into account the child’s disabilities (such as physical and cognitive impairments) or linguistic and other communication difficulties and taken into account the child’s primary language? YES NO YES NO YES NO YES NO YES NO YES NO YES NO 45 Is the child morphologically suitable for electrode placement? Is the child physically fit for surgery and rehabilitation? Is there a willingness and commitment from parents and child to participation in implantation and longterm rehabilitation programme ? Have the parents and child been counselled and have realistic expectations of the outcome of implantation? Is there support from relevant local services ? YES NO YES NO YES NO YES NO YES NO 46 Appendix F CHECK LIST FOR APPLICATION FOR CONSIDERING FUNDING FOR COCHLEAR IMPLANTS IN OVER 18’S Please complete the check list below to indicate which of the following criteria the patient meets Does the patient already have a cochlear implant? YES NO YES NO YES NO Does the patient receive adequate YES benefit from acoustic hearing aids? Has the patient had a multidisciplinary assessment? YES NO Does the patient have severe to profound deafness (defined as hearing only sounds that are louder than 90dB HL at 2 and 4kHz without acoustic hearing aids in the better hearing ear) ? Please provide relevant test results Has the patient had a minimum of 3 months use of optimal digital hearing aids, prior to referral for assessment (unless contraindicated or inappropriate)? Does the patient have a score of less than 50% on the Bamford-KowalBench (BKB) sentence testing at a sound intensity of 70 dB SPL ? Please provide relevant test results Has testing taken into account the patient’s disabilities (such as physical and cognitive impairments) or linguistic and other communication difficulties and taken into account their primary language? NO YES NO YES NO Is the patient morphologically suitable 47 for electrode placement? YES NO Is the patient physically fit for surgery and rehabilitation? YES NO YES NO YES NO YES NO YES NO Is there a willingness and commitment from the patient to participation in implantation and a long-term rehabilitation programme ? Has the patient been counselled and has realistic expectations of the outcome of implantation? Is there support from relevant local services ? Is the patient blind or has other disabilities that increase their reliance on auditory stimuli as a primary sensory mechanism for spatial awareness ? 48 APPENDIX G CHECK LIST FOR APPLICATION FOR CONSIDERING FUNDING FOR BONE ANCHORED HEARING AIDS Please complete the check list below to indicate which of the following criteria the patient meets Does the patient have abnormalities of the middle, outer or external parts the ear or a chronic ear infection, which makes wearing a conventional hearing aid difficult or impossible ? YES NO YES NO YES NO YES NO Is the patient able to keep the area around the fixture clean ? YES NO Does the patient have more than 3mm of bone at the implant site ? YES NO YES NO Does the patient have at least moderate permanent hearing loss in one or both ears (≥41-60dB) that cannot be effectively treated by conventional audiological, medical or surgical interventions e.g. cannot be operated on and for which conventional hearing aids are not felt to suitable ? Please provide the relevant test results Can the patient hear sounds well via bone conduction ? Can the patient understand 60% or more of speech on a standard test I.e word recognition scores), using bone conduction ? Is the patient older than 5 years ? Does the patient have sufficient 49 manual dexterity to remove or attach the external processor ? Is the patient able to accept the abutment that protrudes from the side of the head ? YES NO YES NO 50